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radiaterMike

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Someone calculates or quotes a number from published data and someone else says "This is just an illusion." This is not the full picture. These numbers are low, because my feelings tell me so. Pay no attention to the man behind the curtain.

I'm tired of all the digging. Every time somebody digs it's like "Whoa these vetted and published numbers, and multiplication/division as mathematical operators, can't be right!" In theory ASTRO should be digging and telling what's what. Good luck with that.
I agree with most of what you said but if you scroll up just one post from yours you can see that those calculations didn’t include all of the numbers. Maybe you are a highly motivated person and want to crunch the numbers.
 

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This is for UNC. Duke applied for a CON a few years back. I don't know if anything happened with that but it is conceivable that the Durham/Raleigh/CH area could have 2 proton centers in the near(ish) future.

Literally says Levine Cancer Institute and Atrium Health my dude/dudette.

This is Charlotte/SERO.
 
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ramsesthenice

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Literally says Levine Cancer Institute and Atrium Health my dude/dudette.

This is Charlotte/SERO.
Yep. That is what one gets for not even clicking the link.

Point remains. Lots o' protons headed to the Carolinas.
 
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TheWallnerus

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This is from U Penn's price transparency. The example here is a 30 fraction IMRT Medicare case for a given generic diagnosis (no IGRT) versus the same case treated in 30 fractions with commercial protons or commercial IMRT. The "average" is not what you may think. It just means that out of, say, 20 commercial payors, this is the "average" of all 20. Maybe 90% of their commercial payor mix is the "max," but that would not skew the "average" if that makes sense. So even with price transparency you still don't have a great idea of what centers are making without payor mix data. Maybe they get the "average" once a year and the "max" a thousand times a year... who knows.

That said...

For Medicare, Penn will get about $22,000.
For the same case treated the same way from their best private insurance payor they will get $249,000.
(This is about a 11x price difference.)
For the "average" payor, and "average" IMRT case, they'll get $78,000 (still a nice profit margin).
For the same case treated with protons from their best private insurance payor they will get $480,000.
(This is about a 22x price difference.)

I don't know if this is abuse or not, but it at least feels like heavy petting. A quarter million for a "standard" course of IMRT, and a half million for a "standard" course of protons. Awesome. In essence, an "academic proton physician" could theoretically cover his entire salary and professional overhead with just two commercial proton patients per year (or 5-10 commercial IMRTs).

 
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RickyScott

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This is from U Penn's price transparency. The example here is a 30 fraction IMRT Medicare case for a given generic diagnosis (no IGRT) versus the same case treated in 30 fractions with commercial protons or commercial IMRT. The "average" is not what you may think. It just means that out of, say, 20 commercial payors, this is the "average" of all 20. Maybe 90% of their commercial payor mix is the "max," but that would not skew the "average" if that makes sense. So even with price transparency you still don't have a great idea of what centers are making without payor mix data. Maybe they get the "average" once a year and the "max" a thousand times a year... who knows.

That said...

For Medicare, Penn will get about $22,000.
For the same case treated the same way from their best private insurance payor they will get $249,000.
(This is about a 11x price difference.)
For the "average" payor, and "average" IMRT case, they'll get $78,000 (still a nice profit margin).
For the same case treated with protons from their best private insurance payor they will get $480,000.
(This is about a 22x price difference.)

I don't know if this is abuse or not, but it at least feels like heavy petting. A quarter million for a "standard" course of IMRT, and a half million for a "standard" course of protons. Awesome. In essence, an "academic proton physician" could theoretically cover his entire salary and professional overhead with just two commercial proton patients per year (or 5-10 commercial IMRTs).

It is frank theft from vulnerable cancer pts and their families and employers. (At least credit penn for being transparent. I can’t imagine the bills from some of the other players) It is technically legal, but that has no bearing on the ethics here. Of course, SDNers are the misanthropes and “uncivilized” players, not those involved in defrauding our country.

During hurricanes and natural disasters, price gouging water and gas etc is illegal- just saying.
 
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TheWallnerus

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It is frank theft from vulnerable cancer pts and their families and employers. (At least credit penn for being transparent. I can’t imagine the bills from some of the other players) It is technically legal, but that has no bearing on the ethics here. Of course, SDNers are the misanthropes and “uncivilized” players, not those involved in defrauding our country.

During hurricanes and natural disasters, price gouging water and gas etc is illegal- just saying.
But to pay $500K for protons at the proton center versus $50K for 9 weeks of IMRT at the abusive freestanding center... I mean it's the obvious decision. Right?

 
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fiji128

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This is from U Penn's price transparency. The example here is a 30 fraction IMRT Medicare case for a given generic diagnosis (no IGRT) versus the same case treated in 30 fractions with commercial protons or commercial IMRT. The "average" is not what you may think. It just means that out of, say, 20 commercial payors, this is the "average" of all 20. Maybe 90% of their commercial payor mix is the "max," but that would not skew the "average" if that makes sense. So even with price transparency you still don't have a great idea of what centers are making without payor mix data. Maybe they get the "average" once a year and the "max" a thousand times a year... who knows.

That said...

For Medicare, Penn will get about $22,000.
For the same case treated the same way from their best private insurance payor they will get $249,000.
(This is about a 11x price difference.)
For the "average" payor, and "average" IMRT case, they'll get $78,000 (still a nice profit margin).
For the same case treated with protons from their best private insurance payor they will get $480,000.
(This is about a 22x price difference.)

I don't know if this is abuse or not, but it at least feels like heavy petting. A quarter million for a "standard" course of IMRT, and a half million for a "standard" course of protons. Awesome. In essence, an "academic proton physician" could theoretically cover his entire salary and professional overhead with just two commercial proton patients per year (or 5-10 commercial IMRTs).


Well that explains why UPenn is opening a proton center in rural Lancaster County.

 
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fiji128

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This from the folks that also published on a need for an pre approved community palliative care network to work against unscrupulous over fractionation. What a joke.
 
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TheWallnerus

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Looks like ASTRO is finally condemning this.

I won’t say this directly to a proton MD but I will say it in general to the investors, admins, chairmen, etc, overseeing proton therapy.

It’s like the scene in the Big Short where Mark Baum meets the CDO manager in the sushi restaurant and the CDO mgr says “You think I’m a parasite don’t you? But apparently society values me very much.”
 
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OTN

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Man, Penn's proton program continues to be doing very well indeed
Until each and every other major academic medical center releases their charges, I think it's safe to assume every one of them are doing precisely what UPenn is doing.

Renders the Choosing Wisely/Financial Toxicity academic crowd completely powerless in the whole discussion, and gives significant credence to the idea that perhaps these academic institutions are promoting such work as a smokescreen to avoid scrutiny of their abhorrent practices.
 
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ramsesthenice

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I will never understand insurance carriers. I will never understand how 20 min after having to put together a 3D plan for comparison to get coverage for IMRT for a definitive prostate case (which I have to do now that evicore is covering prior authorizations in our area) I can find out places are actually recovering ludicrous charges for proton therapy without a single ounce of positive toxicity data. Why are any payors shelling out for this?

And anyone who is surprised by the charges they are requesting hasn't been paying attention. Politics is politics in government and academics. You may remember a prominent candidate bragging that cheating the tax code makes them smart. None of our "leaders" are any different. My initial gut instinct was along the lines of don't hate the player, hate the game. But then I remembered a lot of these people are actively shaming others for not choosing wisely :mad:
 
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RickyScott

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I will never understand insurance carriers. I will never understand how 20 min after having to put together a 3D plan for comparison to get coverage for IMRT for a definitive prostate case (which I have to do now that evicore is covering prior authorizations in our area) I can find out places are actually recovering ludicrous charges for proton therapy without a single ounce of positive toxicity data. Why are any payors shelling out for this?

And anyone who is surprised by the charges they are requesting hasn't been paying attention. Politics is politics in government and academics. You may remember a prominent candidate bragging that cheating the tax code makes them smart. None of our "leaders" are any different. My initial gut instinct was along the lines of don't hate the player, hate the game. But then I remembered a lot of these people are actively shaming others for not choosing wisely :mad:
these high end insurances are acting as middlemen/transaction managers. They take 10% or so of the transaction, so high prices are in their interests. Often the “premium” insurances are for large unions- teachers or government workers. For risked based plans like Medicare advantage, payors are very cost conscious.
 
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TheWallnerus

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I will never understand insurance carriers. I will never understand how 20 min after having to put together a 3D plan for comparison to get coverage for IMRT for a definitive prostate case (which I have to do now that evicore is covering prior authorizations in our area) I can find out places are actually recovering ludicrous charges for proton therapy without a single ounce of positive toxicity data. Why are any payors shelling out for this?

And anyone who is surprised by the charges they are requesting hasn't been paying attention. Politics is politics in government and academics. You may remember a prominent candidate bragging that cheating the tax code makes them smart. None of our "leaders" are any different. My initial gut instinct was along the lines of don't hate the player, hate the game. But then I remembered a lot of these people are actively shaming others for not choosing wisely :mad:
these high end insurances are acting as middlemen/transaction managers. They take 10% or so of the transaction, so high prices are in their interests. Often the “premium” insurances are for large unions- teachers or government workers. For risked based plans like Medicare advantage, payors are very cost conscious.
RickyScott is exactly right and it's one of the most confoundingly counterintuitive facts-of-life in modern medicine IMHO.

It’s all farce and façade. It behooves the academic leaders for all of us to fraction shame on SDN and fight with our fellow colleagues across the street while the academics garb themselves in their Pharisaical hypofractionation but make five to ten times as much. Sanctimony is a thrilling emotion when it’s making you rich! The insurance companies get to look good by denying reimbursement to the Joe Shmoes while simultaneously shelling out huge sums to the academic and large hospital meccas. When the insurance pays out the insurance guys get bonuses. Every time a proton place gets $500k for protons, the executive at the proton place AND the insurance executive gets a bonus. The really grind-your-gears part: some of these insurances can pay the academic places so much because they vigorously control cost in the community. Community cancer centers "subsidize" academic places! Wild stuff.

"For risked based plans like Medicare advantage, payors are very cost conscious"... you ain't kidding.
 
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ramsesthenice

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RickyScott is exactly right and it's one of the most confoundingly counterintuitive facts-of-life in modern medicine IMHO.

It’s all farce and façade. It behooves the academic leaders for all of us to fraction shame on SDN and fight with our fellow colleagues across the street while the academics garb themselves in their Pharisaical hypofractionation but make five to ten times as much. Sanctimony is a thrilling emotion when it’s making you rich! The insurance companies get to look good by denying reimbursement to the Joe Shmoes while simultaneously shelling out huge sums to the academic and large hospital meccas. When the insurance pays out the insurance guys get bonuses. Every time a proton place gets $500k for protons, the executive at the proton place AND the insurance executive gets a bonus. The really grind-your-gears part: some of these insurances can pay the academic places so much because they vigorously control cost in the community. Community cancer centers "subsidize" academic places! Wild stuff.

"For risked based plans like Medicare advantage, payors are very cost conscious"... you ain't kidding.
I feel like I need to shower for even being a part of this. Yuck.
 
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wandering star

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these high end insurances are acting as middlemen/transaction managers. They take 10% or so of the transaction, so high prices are in their interests. Often the “premium” insurances are for large unions- teachers or government workers. For risked based plans like Medicare advantage, payors are very cost conscious.
This was discussed in a recent Freakonomics podcast on why U.S. healthcare costs are broken. During the development of Obamacare, a group of policymakers and healthcare economists got together to hash out new policy.

One point of contention was the idea of a cap on insurance: for every $1 we pay to insurance, $0.80 would need to go to healthcare costs. The policymakers felt like this was necessary to rein in costs. The healthcare economists worried about perverse incentives, thinking that if you cap out profit in this direction, insurance would respond by seeking out more expensive procedures, higher volume, etc. Over the past ten years this prediction has seemed to be correct.

I found it so fascinating that this error was foreseen, but for political reasons (not so much partisanship as much as "has to make sense to the average American, gotta punish those terrible insurance firms everyone hates") Obamacare ended up codifying a policy that probably did more harm than good to the average American consumer.

One explanation of this I found online:

 
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TheWallnerus

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This was discussed in a recent Freakonomics podcast on why U.S. healthcare costs are broken. During the development of Obamacare, a group of policymakers and healthcare economists got together to hash out new policy.

One point of contention was the idea of a cap on insurance: for every $1 we pay to insurance, $0.80 would need to go to healthcare costs. The policymakers felt like this was necessary to rein in costs. The healthcare economists worried about perverse incentives, thinking that if you cap out profit in this direction, insurance would respond by seeking out more expensive procedures, higher volume, etc. Over the past ten years this prediction has seemed to be correct.

I found it so fascinating that this error was foreseen, but for political reasons (not so much partisanship as much as "has to make sense to the average American, gotta punish those terrible insurance firms everyone hates") Obamacare ended up codifying a policy that probably did more harm than good to the average American consumer.

One explanation of this I found online:

To steal from Tom Eichler, healthcare reform was a protean challenge.
 
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RickyScott

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This was discussed in a recent Freakonomics podcast on why U.S. healthcare costs are broken. During the development of Obamacare, a group of policymakers and healthcare economists got together to hash out new policy.

One point of contention was the idea of a cap on insurance: for every $1 we pay to insurance, $0.80 would need to go to healthcare costs. The policymakers felt like this was necessary to rein in costs. The healthcare economists worried about perverse incentives, thinking that if you cap out profit in this direction, insurance would respond by seeking out more expensive procedures, higher volume, etc. Over the past ten years this prediction has seemed to be correct.

I found it so fascinating that this error was foreseen, but for political reasons (not so much partisanship as much as "has to make sense to the average American, gotta punish those terrible insurance firms everyone hates") Obamacare ended up codifying a policy that probably did more harm than good to the average American consumer.

One explanation of this I found online:

Yup- and part of the reason I post here. Insurance company most commonly acting as a "middleman/transaction managers" for most plans with the employer/union paying the expenses. (Insurances love to be out of the "risk business")

Therefore, the insurance co motivated to "negotiate" highest possible costs/prices. As Vinay Prassad said- if you can have only one slice of pizza, you would want the largest possible pizza. In radonc that means large centers with absurd negotiated prices, who then virtue signal about hypofract/sbrt for competitive advantage (where they probably negotiated the highest prices)
 
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RickyScott

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Yup- and part of the reason I post here. Insurance company most commonly acting as a "middleman/transaction managers" for most plans with the employer/union paying the expenses. (Insurances love to be out of the "risk business")

Therefore, the insurance co motivated to "negotiate" highest possible costs/prices. As Vinay Prassad said- if you can have only one slice of pizza, you would want the largest possible pizza. In radonc that means large centers with absurd negotiated prices, who then virtue signal about hypofract/sbrt for competitive advantage (where they probably negotiated the highest prices)
From a utilitarian philosophical perspective, there is a price point (that has long been past) where the treating doctor is causing more harm than good for society. ie. by treating cancer patients at ultra high rates, they are making the world a worse place. Doing harm by showing up at work, but Dont get me wrong- if I had no alternative, I would be doing this as well.
 
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ramsesthenice

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This was discussed in a recent Freakonomics podcast on why U.S. healthcare costs are broken. During the development of Obamacare, a group of policymakers and healthcare economists got together to hash out new policy.

One point of contention was the idea of a cap on insurance: for every $1 we pay to insurance, $0.80 would need to go to healthcare costs. The policymakers felt like this was necessary to rein in costs. The healthcare economists worried about perverse incentives, thinking that if you cap out profit in this direction, insurance would respond by seeking out more expensive procedures, higher volume, etc. Over the past ten years this prediction has seemed to be correct.

I found it so fascinating that this error was foreseen, but for political reasons (not so much partisanship as much as "has to make sense to the average American, gotta punish those terrible insurance firms everyone hates") Obamacare ended up codifying a policy that probably did more harm than good to the average American consumer.

One explanation of this I found online:


Its maddening but this is what happens when we let maldistributions in resources and power fester. They saw an issue but were worried that if they threatened the big boys that the workaround/reprisal would be worse than the initial issue (and they may have been right). No different than trying to legislate big corporations swallowing profits and engaging in aggressive stock buy backs to start improving benefits and pay for low level workers. You can make them but instead of having 10,000 poorly paid workers you will have 5,000 with better pay and 5,000 newly unemployed individuals. Slow moving train wrecks can be the hardest to stop I am afraid.
 
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FrostyHammer

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Until each and every other major academic medical center releases their charges, I think it's safe to assume every one of them are doing precisely what UPenn is doing.

Renders the Choosing Wisely/Financial Toxicity academic crowd completely powerless in the whole discussion, and gives significant credence to the idea that perhaps these academic institutions are promoting such work as a smokescreen to avoid scrutiny of their abhorrent practices.
As bad as all this sounds, don't miss the forest for the trees- all this proton stuff is a drop in the bucket compared to IO. I know you guys on SDN love self-flagellating with regard to our field, but be fair and realistic to other fields too.

Just. A. Drop. In. The. Bucket. Just dare to imagine how offlabel IO is going to send the world into financial oblivion.
 
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medgator

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As bad as all this sounds, don't miss the forest for the trees- all this proton stuff is a drop in the bucket compared to IO. I know you guys on SDN love self-flagellating with regard to our field, but be fair and realistic to other fields too.

Just. A. Drop. In. The. Bucket. Just dare to imagine how offlabel IO is going to send the world into financial oblivion.
Except those IO guys in academics are busy expanding indications for the private guys, not fraction shaming them while charging multiples of the price they are
 
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RickyScott

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Except those IO guys in academics are busy expanding indications for the private guys, not fraction shaming them while charging multiples of the price they are
high captured prices leads to satellite expansion and buyouts of community practices with expanding departments and residencies.

UPenn has Something like 20 satellites, 2 of which have protons under construction.(virtua and Lancaster)
 
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FrostyHammer

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Except those IO guys in academics are busy expanding indications for the private guys, not fraction shaming them while charging multiples of the price they are
The easiest way to expand indication of an IO drug is to give it offlabel.

And we should know better to think that pompous academic radoncs actually care a lick about PPers...
 
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